20: the average number of veterans a day who died in this country from suicide

14: the number of veterans who are not under VA care

65: the percentage of all veterans who died by suicide who were age 50 or older

67: the percent of all veteran deaths by suicide as a result of firearm injuries

Find out what the VA and Congress are doing to fight this national crisis.

This week, the VA winds down its suicide prevention awareness month campaign and outreach efforts.

During September, the VA released findings of a detailed analysis of veteran suicide data from all 50 states, as well as Puerto Rico and the District of Columbia. The analysis was part of its earlier comprehensive examination of more than 55 million records, from 1979 to 2014, as the VA sought to develop and evaluate suicide prevention across the country.

“These findings are deeply concerning, which is why I made suicide prevention my top clinical priority,” said VA Secretary Dr. David Shulkin in a press release earlier this month.

“I am committed to reducing Veteran suicides through support and education.” Shulkin said. “We know that of the 20 suicides a day that we reported last year, 14 are not under VA care. This is a national public health issue that requires a concerted, national approach.”

Closing out the month, Congress held a hearing this week to consider several bills to address mental health services in the VA and veteran suicides, as well as a hearing on Wednesday, Sept. 27, where Shulkin offered testimony to the Senate Committee on Veterans’ Affairs regarding how he is addressing suicide prevention in his department.

“Suicide is a terrible, terrible loss of life – a preventable loss of life,” said committee chair Sen. Johnny Isakson (R-Ga.) in his opening remarks before the committee. “It is a disease, and it is preventable, and there are many things we can do to set the example, including promoting training through our staff and throughout government.”

As the largest integrated suicide prevention program in the country, the VA has over 1,000 mental health professionals, but more must be done to address the mental health needs of veterans accessing the system, six of whom die by suicide every day, as well as the larger number of veterans-the 14 committing suicide each day who aren’t accessing the system because there are not enough health care providers or because other barriers preventing them from getting the necessary care in or outside the system.

While Shulkin outlined a number of initiatives undertaken in recent months, including establishing a suicide prevention advisory group, developing a patient record flagging system to identify and monitor patients, and establishing a suicide prevention program at every facility, the secretary urged the committee’s support in helping him to get more mental health professionals into the VA system, more research dollars, and more public awareness across America, as suicide is everyone’s business.

“Our goal is to eliminate suicide,” said Shulkin. “As stated earlier, six Americans will die during the course of this hearing – I think about this every day – I think about how many veterans are dying every day because we aren’t effective at addressing this problem.”

He went on to emphasize data show VA health care treatment saves lives, but it can’t help those veterans not in its system. The VA intends to remain committed to eliminating veteran suicides through more aggressive efforts aimed at risk identification, effective treatments, research, and strategic partnerships.

Additionally, the House Committee on Veterans’ Affairs held a hearing the day prior to consider several bills aimed at preventing suicide and providing enhanced care for veterans suffering from mental health conditions. Some of these bills include:

H.R. 2225, Veterans Dog Training Therapy Act-allows the VA to conduct a pilot program on dog training therapy by entering into agreement with certified non-government entities at a minimum of three but not more than five VA medical centers.

The message in both hearings this week was clear: There is much more to be done to reverse the trend on veteran suicides, and MOAA will work with the secretary and members of Congress to make sure the VA has the tools and resources it needs to address this critical public health problem in order to eradicate veteran suicide.

MOAA members can help too. Learn more about the VA’s suicide prevention program and how you can Be There to Save a Life .

Overview

PTSD is a disorder that develops in some people who have experienced a shocking, scary, or dangerous event.

It is natural to feel afraid during and after a traumatic situation. Fear triggers many split-second changes in the body to help defend against danger or to avoid it. This “fight-or-flight” response is a typical reaction meant to protect a person from harm. Nearly everyone will experience a range of reactions after trauma, yet most people recover from initial symptoms naturally. Those who continue to experience problems may be diagnosed with PTSD. People who have PTSD may feel stressed or frightened even when they are not in danger.

Signs and Symptoms

Not every traumatized person develops ongoing (chronic) or even short-term (acute) PTSD. Not everyone with PTSD has been through a dangerous event. Some experiences, like the sudden, unexpected death of a loved one, can also cause PTSD. Symptoms usually begin early, within 3 months of the traumatic incident, but sometimes they begin years afterward. Symptoms must last more than a month and be severe enough to interfere with relationships or work to be considered PTSD. The course of the illness varies. Some people recover within 6 months, while others have symptoms that last much longer. In some people, the condition becomes chronic.

A doctor who has experience helping people with mental illnesses, such as a psychiatrist or psychologist, can diagnose PTSD.

To be diagnosed with PTSD, an adult must have all of the following for at least 1 month:

At least one re-experiencing symptom

At least one avoidance symptom

At least two arousal and reactivity symptoms

At least two cognition and mood symptoms

Re-experiencing symptoms include:

Flashbacks—reliving the trauma over and over, including physical symptoms like a racing heart or sweating

Bad dreams

Frightening thoughts

Re-experiencing symptoms may cause problems in a person’s everyday routine. The symptoms can start from the person’s own thoughts and feelings. Words, objects, or situations that are reminders of the event can also trigger re-experiencing symptoms.

Avoidance symptoms include:

Staying away from places, events, or objects that are reminders of the traumatic experience

Avoiding thoughts or feelings related to the traumatic event

Things that remind a person of the traumatic event can trigger avoidance symptoms. These symptoms may cause a person to change his or her personal routine. For example, after a bad car accident, a person who usually drives may avoid driving or riding in a car.

Arousal and reactivity symptoms include:

Being easily startled

Feeling tense or “on edge”

Having difficulty sleeping

Having angry outbursts

Arousal symptoms are usually constant, instead of being triggered by things that remind one of the traumatic events. These symptoms can make the person feel stressed and angry. They may make it hard to do daily tasks, such as sleeping, eating, or concentrating.

Cognition and mood symptoms include:

Trouble remembering key features of the traumatic event

Negative thoughts about oneself or the world

Distorted feelings like guilt or blame

Loss of interest in enjoyable activities

Cognition and mood symptoms can begin or worsen after the traumatic event, but are not due to injury or substance use. These symptoms can make the person feel alienated or detached from friends or family members.

It is natural to have some of these symptoms after a dangerous event. Sometimes people have very serious symptoms that go away after a few weeks. This is called acute stress disorder, or ASD. When the symptoms last more than a month, seriously affect one’s ability to function, and are not due to substance use, medical illness, or anything except the event itself, they might be PTSD. Some people with PTSD don’t show any symptoms for weeks or months. PTSD is often accompanied by depression, substance abuse, or one or more of the other anxiety disorders.

Do children react differently than adults?

Children and teens can have extreme reactions to trauma, but their symptoms may not be the same as adults. In very young children (less than 6 years of age), these symptoms can include:

Wetting the bed after having learned to use the toilet

Forgetting how to or being unable to talk

Acting out the scary event during playtime

Being unusually clingy with a parent or other adult

Older children and teens are more likely to show symptoms similar to those seen in adults. They may also develop disruptive, disrespectful, or destructive behaviors. Older children and teens may feel guilty for not preventing injury or deaths. They may also have thoughts of revenge. For additional information, visit the Learn More section below. The National Institute of Mental Health (NIMH) offers free print materials in English and Spanish. These can be read online, downloaded, or delivered to you in the mail.

Risk Factors

Anyone can develop PTSD at any age. This includes war veterans, children, and people who have been through a physical or sexual assault, abuse, accident, disaster, or many other serious events. According to the National Center for PTSD , about 7 or 8 out of every 100 people will experience PTSD at some point in their lives. Women are more likely to develop PTSD than men, and genes may make some people more likely to develop PTSD than others.

Not everyone with PTSD has been through a dangerous event. Some people develop PTSD after a friend or family member experiences danger or harm. The sudden, unexpected death of a loved one can also lead to PTSD.

Why do some people develop PTSD and other people do not?

It is important to remember that not everyone who lives through a dangerous event develops PTSD. In fact, most people will not develop the disorder.

Many factors play a part in whether a person will develop PTSD. Some examples are listed below. Risk factors make a person more likely to develop PTSD. Other factors, called resilience factors, can help reduce the risk of the disorder.

Risk Factors and Resilience Factors for PTSD

Some factors that increase risk for PTSD include:

Living through dangerous events and traumas

Getting hurt

Seeing another person hurt, or seeing a dead body

Childhood trauma

Feeling horror, helplessness, or extreme fear

Having little or no social support after the event

Dealing with extra stress after the event, such as loss of a loved one, pain and injury, or loss of a job or home

Having a history of mental illness or substance abuse

Some resilience factors that may reduce the risk of PTSD include:

Seeking out support from other people, such as friends and family

Finding a support group after a traumatic event

Learning to feel good about one’s own actions in the face of danger

Having a positive coping strategy, or a way of getting through the bad event and learning from it

Being able to act and respond effectively despite feeling fear

Researchers are studying the importance of these and other risk and resilience factors, including genetics and neurobiology. With more research, someday it may be possible to predict who is likely to develop PTSD and to prevent it.

Treatments and Therapies

The main treatments for people with PTSD are medications, psychotherapy (“talk” therapy), or both. Everyone is different, and PTSD affects people differently so a treatment that works for one person may not work for another. It is important for anyone with PTSD to be treated by a mental health provider who is experienced with PTSD. Some people with PTSD need to try different treatments to find what works for their symptoms.

If someone with PTSD is going through an ongoing trauma, such as being in an abusive relationship, both of the problems need to be addressed. Other ongoing problems can include panic disorder, depression, substance abuse, and feeling suicidal.

Medications

The most studied medications for treating PTSD include antidepressants, which may help control PTSD symptoms such as sadness, worry, anger, and feeling numb inside. Antidepressants and other medications may be prescribed along with psychotherapy. Other medications may be helpful for specific PTSD symptoms. For example, although it is not currently FDA approved, research has shown that Prazosin may be helpful with sleep problems, particularly nightmares, commonly experienced by people with PTSD.

Doctors and patients can work together to find the best medication or medication combination, as well as the right dose. Check the U.S. Food and Drug Administration website (http://www.fda.gov/ ) for the latest information on patient medication guides, warnings, or newly approved medications.

Psychotherapy

Psychotherapy (sometimes called “talk therapy”) involves talking with a mental health professional to treat a mental illness. Psychotherapy can occur one-on-one or in a group. Talk therapy treatment for PTSD usually lasts 6 to 12 weeks, but it can last longer. Research shows that support from family and friends can be an important part of recovery.

Many types of psychotherapy can help people with PTSD. Some types target the symptoms of PTSD directly. Other therapies focus on social, family, or job-related problems. The doctor or therapist may combine different therapies depending on each person’s needs.

Effective psychotherapies tend to emphasize a few key components, including education about symptoms, teaching skills to help identify the triggers of symptoms, and skills to manage the symptoms. One helpful form of therapy is called cognitive behavioral therapy, or CBT. CBT can include:

Exposure therapy. This helps people face and control their fear. It gradually exposes them to the trauma they experienced in a safe way. It uses imagining, writing, or visiting the place where the event happened. The therapist uses these tools to help people with PTSD cope with their feelings.

Cognitive restructuring. This helps people make sense of the bad memories. Sometimes people remember the event differently than how it happened. They may feel guilt or shame about something that is not their fault. The therapist helps people with PTSD look at what happened in a realistic way.

There are other types of treatment that can help as well. People with PTSD should talk about all treatment options with a therapist. Treatment should equip individuals with the skills to manage their symptoms and help them participate in activities that they enjoyed before developing PTSD.

How Talk Therapies Help People Overcome PTSD
Talk therapies teach people helpful ways to react to the frightening events that trigger their PTSD symptoms. Based on this general goal, different types of therapy may:

Teach about trauma and its effects

Use relaxation and anger-control skills

Provide tips for better sleep, diet, and exercise habits

Help people identify and deal with guilt, shame, and other feelings about the event

Focus on changing how people react to their PTSD symptoms. For example, therapy helps people face reminders of the trauma.

Beyond Treatment: How can I help myself?

It may be very hard to take that first step to help yourself. It is important to realize that although it may take some time, with treatment, you can get better. If you are unsure where to go for help, ask your family doctor. You can also check NIMH’s Help for Mental Illnesses page or search online for “mental health providers,” “social services,” “hotlines,” or “physicians” for phone numbers and addresses. An emergency room doctor can also provide temporary help and can tell you where and how to get further help.
To help yourself while in treatment:

Talk with your doctor about treatment options

Engage in mild physical activity or exercise to help reduce stress

Set realistic goals for yourself

Break up large tasks into small ones, set some priorities, and do what you can as you can

Try to spend time with other people, and confide in a trusted friend or relative. Tell others about things that may trigger symptoms.

Expect your symptoms to improve gradually, not immediately

Identify and seek out comforting situations, places, and people

Caring for yourself and others is especially important when large numbers of people are exposed to traumatic events (such as natural disasters, accidents, and violent acts). For more information, see the Learn More section, below.

Next Steps for PTSD Research

In the last decade, progress in research on the mental and biological foundations of PTSD has lead scientists to focus on better understanding the underlying causes of why people experience a range of reactions to trauma.

Other research is looking at how fear memories are affected by learning, changes in the body, or even sleep.

Research on preventing the development of PTSD soon after trauma exposure is also under way.

Still other research is attempting to identify what factors determine whether someone with PTSD will respond well to one type of intervention or another, aiming to develop more personalized, effective, and efficient treatments.

As gene research and brain imaging technologies continue to improve, scientists are more likely to be able to pinpoint when and where in the brain PTSD begins. This understanding may then lead to better targeted treatments to suit each person’s own needs or even prevent the disorder before it causes harm.

Join a Study

What are Clinical Trials?

Clinical trials are research studies that look at new ways to prevent, detect, or treat diseases and conditions, including PTSD. During clinical trials, treatments might be new drugs or new combinations of drugs, new surgical procedures or devices, or new ways to use existing treatments. The goal of clinical trials is to determine if a new test or treatment works and is safe. Although individual participants may benefit from being part of a clinical trial, participants should be aware that the primary purpose of a clinical trial is to gain new scientific knowledge so that others may be better helped in the future.

Please Note: Decisions about whether to apply for a clinical trial and which ones are best suited for a given individual are best made in collaboration with your licensed health professional.

How do I find Clinical Trials at NIMH on PTSD?

Doctors at NIMH are dedicated to mental health research. The studies take place at the NIH Clinical Center in Bethesda, Maryland and require regular visits. After the initial phone interview, you will come to an appointment at the clinic and meet with one of our clinicians. Find NIH-funded studies currently recruiting participants with PTSD by using ClinicalTrials.gov (search: PTSD).

How Do I Find a Clinical Trial Near Me?

To search for a clinical trial near you, you can visit ClinicalTrials.gov . This is a searchable registry and results database of federally and privately supported clinical trials conducted in the United States and around the world. ClinicalTrials.gov gives you information about a trial’s purpose, who may participate, locations, and phone numbers to call for more details. This information should be used in conjunction with advice from health professionals.

Learn More

Free Booklets and Brochures

You can download or order free copies of the following booklets and brochures in English or en Español:

Multimedia

Watch: Dr. Daniel Pine on Boosting Resilience to PTSD: Dr. Daniel Pine on a NIH study that tracked Israeli soldiers through deployment to ID predictors. Study found that soldiers preoccupied with threat at the time of enlistment or with avoiding it just before deployment were more likely to develop post-traumatic stress disorder (PTSD).

Federal Resources

The National Center for PTSD, part of the U.S. Department of Veterans Affairs, has a website with targeted information for anyone interested in PTSD (including veterans, family, and friends) and for professional researchers and health care providers. The site also offers videos and information about an online app called PTSD Coach.

Information for the general public: The National Center for PTSD offers a page of resources for people who have experienced an act of terrorism. Materials include resources for survivors and the public, tips for veterans coping with violent events, and suggestions for helping caregivers respond to children.

Despite change in leadership and promises to address ongoing problems with its veteran suicide line, nearly 30 percent of calls to the Department of Veterans Affairs were redirected to outside emergency centers, according to an inspector general report released Monday.

“We found that [Veterans Crisis Line] staff did not respond adequately to a veteran’s urgent needs during multiple calls to the VCL and its backup call centers,” the report said.

When the VCL program was started in 2007, VA management initially estimated that approximately 10 percent of calls would be rolled over to a backup center.

In fact, call rollover to backup centers increased between April and November 2016, peaking at more than 108,000, or a 28.4 percent rate.

In November, calls to the backup centers hit a peak of nearly 18,000 – a nearly 35 percent rollover rate.

In February 2016, the IG issued a report detailing how some suicide calls were being sent to voicemail or callers did not always receive immediate assistance from VCL and/or backup center staff.

The IG then called for the department to implement seven separate recommendations, but as of December 16, 2016 none were in place, Monday’s report said.

House Committee on Veterans’ Affairs Chairman Phil Roe, M.D. (R-Tenn.) expressed frustration, saying it is “unacceptable that issues with the Veterans Crisis Line have still not been addressed.”

“The findings in this latest report identify an unacceptable disconnect between the Clinical Advisory Board and the Veterans Crisis Line in obtaining the clinical input necessary to make policy decisions. The Veterans Crisis Line should be collaborating with clinical services every step of the way,” he said in a statement.

Amanda Maddox, spokesperson for Isakson, told Fox News the committee was “informed by the inspector general that they do not believe there is a need for legislation. Our committee is currently looking into additional oversight options as well.

The IG also reported that management had not set any standards for the length of wait times when a veteran calls.

“We found that VCL leadership had not established expectations or targets for queued call times or thresholds for taking action on queue times. A veteran could be queued for 30 minutes, for example, and that wait time might not be reflected in hold time data; however, the result of the delay is the same, whether the veteran was in a queue or on hold,” the IG said.

The IG also criticized the absence of sustained and permanent leadership at the VCL, which functioned without a director for 10 months in 2015 before a permanent replacement was named.

But that director resigned in June 2016 and as of December 2016, no permanent director has been hired. Furthermore, supervisory staff did not identify the deficiencies in their internal review of the matter.

Recent veterans have committed suicide at a much higher rate than people who never served in the military, according to a new analysis that provides the most thorough accounting so far of the problem.

The rate was slightly higher among veterans who never deployed to Afghanistan or Iraq, suggesting that the causes extend beyond the trauma of war.

“People’s natural instinct is to explain military suicide by the war-is-hell theory of the world,” said Michael Schoenbaum, an epidemiologist and military suicide expert at the National Institute of Mental Health who was not involved in the study. “But it’s more complicated.”

The study brings precision to a question that has never been definitively answered: the actual number of suicides since the start of the recent wars.

Though past research has also found elevated suicide rates, those results were estimates based on smaller samples and less reliable methods to identify veteran deaths. The government has not systematically tracked service members after they leave the military.

“People’s natural instinct is to explain military suicide by the war-is-hell theory of the world. But it’s more complicated.”
— Michael Schoenbaum, an epidemiologist and military suicide expert at the National Institute of Mental Health

The new analysis, which will be published in the February issue of the Annals of Epidemiology, included all 1,282,074 veterans who served in active-duty units between 2001 and 2007 and left the military during that period.

The analysis matched military records with the National Death Index, which collects data on every U.S. death. It tracked the veterans after service until the end of the 2009, finding a total of 1,868 suicides.

That equates to an annual suicide rate of 29.5 per 100,000 veterans, or roughly 50% higher than the rate among other civilians with similar demographic characteristics.

The issue of veteran suicide has become a political cause for activists and legislators. One statistic has become a rallying cry: 22 veterans take their own lives each day.

That figure is a national estimate based on a Department of Veterans Affairs analysis of death records from 21 states. Though it is usually cited in the context of the recent wars, most of those suicides involved older veterans, who account for the vast majority of the nation’s 22 million former service members.

Among veterans in the current study, there was one suicide a day.

The rates were highest during the first three years out of the military.

Veterans who had been enlisted in the rank-and-file committed suicide at nearly twice the rate of former officers. Keeping with patterns in the general population, being white, unmarried and male were also risk factors.

Men accounted for 83% of the veterans in the study and all but 124 of the suicides. They were three times more likely than women to take their own lives.

Female veterans, however, killed themselves at more than twice the rate of other women — a difference much bigger than the gap between male veterans and non-veterans.

A likely explanation is that women with military experience are much more likely than other women to attempt suicide with firearms, dramatically increasing the likelihood of death, said Mark Kaplan, an epidemiologist and suicide expert at UCLA.

Overall, the suicide rates for recent veterans set them apart from veterans of past generations.

In the Vietnam era, suicide rates were elevated for veterans suffering from post-traumatic stress or those wounded in action. But on the whole, suicide rates for veterans in their first few years out of the military were lower than in the general population, according to research.

The elevated rate today could reflect differences in who served, the study’s authors speculate. In the days of the draft, troops represented a wider cross-section of society. The long wars in Afghanistan and Iraq may have attracted more volunteers prone to risk-taking and impulsive behaviors.

“We don’t have the data to know,” said Tim Bullman, a mortality expert and health statistician at the VA and coauthor of the paper.

Another possibility, he said, is that a weak economy during the recent wars made the transition to civilian life more difficult.

More puzzling is the suicide rate for veterans who never went to Afghanistan or Iraq. It was 16% higher than for those who did.

Bullman said one reason could be that service members with psychological problems were often held back from deployment. He added that that suicide prevention efforts had focused on service members and veterans who did go to war.

Experts have also suggested that the military may have become a less forgiving and nurturing place over the course of the wars. “The stresses are not limited to the individuals who are sent to war,” Schoenbaum said.

A more detailed accounting of veteran mortality is on the horizon. A massive new data trove is being assembled by the Pentagon and the VA. Known as the Suicide Data Repository, it links national death records to military and healthcare data.

Among veterans who have served since 1974, the project has identified more than 2 million deaths of all types between 1979 and 2011, according to Robert Bossarte, a VA epidemiologist helping oversee the effort.

For each death, researchers will be able to learn the veteran’s deployment history, education and other information.

Researchers plan to build on the current study — which does not include reservists or veterans who served after 2007 — and look at suicide rates for all 3.7 million veterans who served since 2001.

February 8, 2017 / icg / Comments Off on A General’s New Mission: Leading a Charge Against PTSD

Brig. Gen. Donald C. Bolduc, commander of American Special Operations Forces in Africa, tells soldiers that it is all right to get help for brain injuries and mental health problems. CreditAndrew Harnik/Associated Press

STUTTGART, Germany — It might have been the 2,000-pound bomb that dropped near him in Afghanistan, killing several comrades. Or maybe it was the helicopter crash he managed to survive. It could have been the battlefield explosions that detonated all around him over eight combat tours.

Whatever the cause, the symptoms were clear. Brig. Gen. Donald C. Bolduc suffered frequent headaches. He was moody. He could not sleep. He was out of sorts; even his balance was off. He realized it every time he walked down the street holding hands with his wife, Sharon, leaning into her just a little too close.

Despite all the signs of post-traumatic stress disorder, it took 12 years from his first battlefield trauma for him to seek care. After all, he thought, he was a Green Beret in the Army’s Special Forces. He needed to be tough.

General Bolduc learned that not only did he suffer from PTSD, but he also had a bullet-size spot on his brain, an injury probably dating to his helicopter crash in Afghanistan in 2005.

Now, after three years of treatment, General Bolduc is doing better. And, in his role as commander of American Special Operations Forces in Africa, he has become an evangelist for letting soldiers know that it is all right to get help for brain injuries and mental health problems.

“I’ve really seen a difference in myself,” General Bolduc, 54, said. “There are still the nonbelievers. We’ve got to get to them.”

That means changing attitudes that equate mental illness with weakness. Donald J. Trump, the Republican presidential candidate,said in a speech this week that some veterans returning from war “can’t handle” the stress. Mr. Trump was arguing for mental health services, but the remark drew scorn from veterans’ groups that work to reduce the stigma. Mr. Trump’s campaign has said his remarks were taken out of context. A spokesman for General Bolduc declined to comment.

On a recent afternoon, General Bolduc, his starched uniform weighed down by a giant patch of colorful ribbons and medals across his chest, stood ramrod straight at the Stuttgart headquarters from which he commands Special Operations fighters battling the Islamic State, Boko Haram, the Shabab and other terrorist groups in Africa, and he declared, “I’m in counseling.”

General Bolduc wants soldiers under his command — who are stationed in some of the continent’s most difficult parts — to know that seeking help will not hurt their careers. In his opinion, PTSD is the same as a broken arm.

“The powerful thing is that I can use myself as an example,” General Bolduc said. “And thank goodness not everybody can do that. But I’m able to do it, so that has some sort of different type of credibility to it.”

Other high-ranking officers have come forward to talk about their struggles with post-combat stress and brain injuries. And in recent years, Special Operations commanders have become more open about urging their soldiers to get treatment.

Gen. Joseph L. Votel, then the head of the United States Special Operations Command, spoke to CNN last spring about ending the stigma tied to seeking treatment. “It is absolutely normal and expected that you will ask for help,” he said.

The stigma can be particularly acute in specialized military units, like the Green Berets and the Navy SEALs, that are trained for the toughest assignments and consider intervention a sign of weakness.
Yet the Department of Defense estimates that almost a quarter of all injuries suffered in the conflicts in Afghanistan and Iraq were brain injuries. As many as 20 percent of veterans of those two conflicts experience PTSD.

Traumatic brain injuries and PTSD share symptoms like headaches, depression and, sometimes, suicidal behavior. The consequences of not getting help can be severe: In the past four years, more than 2,000 active and reserve military personnel have killed themselves, according to the department.

Across the military base in Stuttgart, suicide prevention and PTSD brochures are positioned on desktops and hallway tables. The base has a Preservation of the Force and Family center, a program created specifically for Special Operations Forces, where anyone can seek help for behavioral issues, including alcohol or drug abuse, and counseling for family and financial problems.

When commanders rented a movie theater last year for a screening of the latest “Star Wars” movie, General Bolduc made sure that the free tickets had to be picked up at the center, to get soldiers comfortable with stepping inside the door.

On base, officers talk openly about mood swings, making their wives cry and other indicators that led them to seek help.

General Bolduc, who took command in April 2015, encourages these kinds of honest conversations. In speeches to his leadership team and in visits to his troops in Africa, and every time a new soldier comes into his fold, he tells his personal story and urges anyone experiencing the same kinds of symptoms to get help.

A native of Laconia, N.H., General Bolduc said he had wanted to join the Special Forces ever since as a young boy he watched the movie “The Green Berets” with his grandfather.

“For all Bolduc males, service to country is a requirement,” said General Bolduc, whose two brothers also joined the Special Forces. “My grandfather didn’t care what service, but he did feel that it was an obligation.”

He earned his ROTC commission in 1989, graduating from Salem State College in Massachusetts, and later earned a master’s degree in security technologies from the United States Army War College.

Last month, General Bolduc awarded a Purple Heart to an airman 11 years after he had received a brain injury during a mortar attack in Iraq. The airman, Tech. Sgt. David Nafe, had experienced memory loss and migraines for years.

General Bolduc made a fuss, summoning his staff to a ceremony for the award. The military publication Stars and Stripes published an articleabout Sergeant Nafe on its front page. In front of the audience gathered for the ceremony, the general told the soldier he could relate to him.

“When people look at you, you look completely normal,” General Bolduc said. “And then they see how you act and they say, ‘God bless, what’s wrong with that guy?’ ”

The Defense Department and the Veterans Health Administration have worked to improve mental health services. Yet many service members do not regularly seek care, according to a 2014 report from the RAND Corporation, a think thank that conducts government studies.

That procrastination is exacerbated by the hypermacho culture of Special Operations, General Bolduc said, where high-stress tours leave members especially vulnerable. Members wait an average of 13 years and 3 months to seek treatment for injuries that are not catastrophic, according to Sarah McNary, a nurse in charge of traumatic brain injury cases at Landstuhl Regional Medical Center in Germany, who first persuaded General Bolduc to submit to a brain examination.

When a bomb dropped on his position in Afghanistan in 2001 — a friendly fire accident — General Bolduc’s hip was badly damaged. He declined medical treatment and pushed ahead with the mission, an offensive on Kandahar, and later needed hip-replacement surgery.

An average-size man at 5-foot-7 and 145 pounds, General Bolduc is so fit and focused that even if he were wearing overalls he would probably be identifiable as a Green Beret. Yet he has a soft side, offering a handshake or a hug to everyone he meets on a stroll around the base.

Now, the general goes to counseling sessions with his wife, who for years urged him to seek treatment.

“The doctors love it because I’m still guarded,” he said. “First of all, you feel funny even talking about it. You’re not likely to give them your real symptoms. But your wife is going to say, ‘That’s a load of crap.’ ”

About a month ago, while visiting a team under his command, General Bolduc asked how many of the men had been close to blasts, bombs and mortar shells. Everyone raised a hand.

“Then I said, ‘How many of you have sought treatment?’ ” he said. “No one’s hand went up.”

General Bolduc told them his own story, and afterward, all of the men decided to get exams. Doctors found a tumor in one soldier’s brain.

He was flown to Walter Reed National Military Medical Center, near Washington, where he is being evaluated.

Sleep disturbance is one of the most common issues individuals with PTSD face. Specifically, insomnia and nightmares plague the vast majority of those struggling with the disorder.

Although it is assumed to be high, relatively little is known about the actual prevalence of sleep disturbances in veterans with PTSD. Any clinician who treats veterans with PTSD will likely tell you that most, if not all, of their patients suffer from sleep problems to some degree.

Relatedly, it is assumed that sleep disturbances improve with evidence-based PTSD treatments. However, to what degree is unclear.

In an effort to gain better clarity on these issues, researchers from the University of Texas Health Science Center at San Antonio, and colleagues from several other prestigious academic institutions, asked these questions to over 100 active-duty service members. Their findings were published in the November issue ofPsychological Traumaand were shocking.

Not surprisingly, insomnia was the most frequently reported PTSD symptom prior to treatment. A whopping 92 percent acknowledged some degree of difficulty falling or staying asleep. Although not as high as insomnia, 69 percent of the same group reported suffering from nightmares.

The surprising, and somewhat disheartening news, is that approximately three-fourths of service members still reported insomnia as a problem after PTSD treatment. And around half still struggled with nightmares.

The researchers took an even deeper look into the results and found additional important information. For those service members who no longer met criteria for PTSD after successful treatment, more than half continued to report insomnia, and 13 percent continued to report problems with nightmares. Again, this is from those troops who made such significant improvement that they no longer had enough symptoms to retain the PTSD diagnosis.

In my opinion, there are two important take-home messages from this study.

First, sleep problems will likely continue in many people with PTSD, even in those service members who benefit greatly from treatment. Therefore, it is important to manage expectations. There are few — if any — complete “cures” in psychology and psychiatry, but this doesn’t mean you can’t go on to lead a rewarding and fulfilling life. Keep in mind, many people without PTSD struggle with sleep.

Second, you may want to ask to be referred for a sleep-focused therapy in addition to the PTSD treatment. Treatments like Imagery Rehearsal Therapy and Cognitive-Behavioral Therapy for Insomnia have been proven successful for nightmares and insomnia.

Bret A. Moore, Psy.D., is a board-certified clinical psychologist who served two tours in Iraq. Email him at kevlarforthemind@militarytimes.com. This column is for informational purposes only and is not intended to convey specific psychological or medical guidance.